Healthcare Provider Details

I. General information

NPI: 1497613426
Provider Name (Legal Business Name): LACEY BROADBENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

561 E TABERNACLE ST
ST GEORGE UT
84770-2944
US

IV. Provider business mailing address

561 E TABERNACLE ST
ST GEORGE UT
84770-2944
US

V. Phone/Fax

Practice location:
  • Phone: 435-673-2899
  • Fax:
Mailing address:
  • Phone: 435-673-2899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11692744-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: